Nurse Staffing and Patient Outcomes
Study Workgroup – March 25, 2014
Meeting Summary (DRAFT)
Meeting Details
Date: March 25, 2014
Start/End Time: 1:30 pm – 3:00 pm
Location: Stassen Office Building, St. Paul
Project champion: Diane Rydrych, Minnesota Department of Health (MDH)
MDH project staff: Stefan Gildemeister and Nate Hierlmaier
Facilitator: Kris Van Amber, Management Analysis & Development (MAD), Minnesota Management and
Budget
Workgroup members present: Connie Delaney, University of Minnesota School of Nursing; Marie
Dotseth, Minnesota Alliance for Patient Safety; Linda Hamilton, Minnesota Nurses Association
(MNA)/ Minneapolis Children's Hospital; Betsy Jeppesen, Stratis Health; Sandra “Mac” McCarthy,
Essentia Health; Christine Milbrath, Metropolitan State University Steven Mulder, Hutchinson
Health; Maribeth Olson, Mercy Hospital - Allina Health; Robert Pandiscio, Minnesota Nurses
Association; Sandy Potthoff, University of Minnesota School of Public Health; Eric Tronnes, Abbott
Northwestern/MNA; Vonda Vaden Bates, patient representative (by phone).
Others present (based on sign-in sheet): Wendy Burt, Minnesota Hospital Association (MHA); Shannon
Cunningham, MNA; Walt Fredrickson, MNA; Sarah Ford, MHA; Keri Garden, Allina; James McClean,
HealthPartners; Keri Nelson, MNA; Janice Schade, Essentia St. Mary’s; Nikki Vilendrer, Mayo; Anna
Youngerman, Children’s Hospitals and Clinics.
Workgroup member unable to attend: Shirley Brekken, Minnesota Board of Nursing
Welcome and introductions
Stefan Gildemeister and Diane Rydrych welcomed the group to the meeting. Kris Van Amber provided
an overview of the agenda for the meeting. Kris asked members of the workgroup to identify
themselves and their organization.
Stefan thanked the group for their continued participation. Since the last meeting, MDH staff has been
working to develop options for the study. The hope for today’s meeting is to have initial discussions of
those options and do some level-setting about the type of study MDH can do within the time allotted.
Stefan reminded the group that the study is due to the legislature in January 2015. MDH hopes to bring
this group back together towards the end of this year to think through what has been accomplished and
to hear the group’s thoughts on the findings and limitations of the study.
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Recap of advice from the workgroup
Beth Bibus from MAD provided a summary of the workgroup’s advice on nurse staffing data. The
summary is available on the MDH website: Handout – Summary of Workgroup Advice on Staffing
Measures. The document includes an overview of group’s discussion of several topics: sources of nurse
staffing data, considerations regarding using staffing data, other important factors that contribute to
patient outcomes (such as variations among patients and variations among hospitals), and key
challenges for the study. Beth invited workgroup members to email her if there are any needed
changes.
Kris asked workgroup members if there were any questions or comments. Discussion included:
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Research reported in a 2010 Institute of Medicine report may be valuable. It covers many
studies correlating staffing and outcomes. Connie Delaney will provide a copy or citation to
MDH.
MDH prepared a reading list for the workgroup early on. The list is available on the MDH
website at: Select Research Summaries on Nurse Staffing Levels and Patient Outcomes
It is important to consider the MDH study as being part of a larger body of evidence—we don’t
have to do things a new way.
There is a pending study of Massachusetts hospitals and CMA ratios. Robert Pandiscio will
forward the citation.
Stefan encouraged workgroup members to continue to send any additional relevant research to MDH.
Reality check
Stefan reminded the group about previous discussions regarding timing, scope, and data sources for the
study of the correlation between nurse staffing and patient outcomes. A copy of the full presentation is
available on the MDH website at: MDH Presentation – Tentative Study Approach.
Stefan discussed the benefits and challenges of using data from the Minnesota Hospital Association’s
staffing reports and the availability of data to account for confounding factors. Data relating to
outcomes is a real concern—despite years of work in the field, it is difficult to find good ways to
measure patient quality and outcomes. Stefan shared MDH’s summary of potential outcome
measures—there is some concordance across different perspectives on these measures and indicators.
As with other elements, there will be difficulty getting to the level of granularity of data or quantity of
observations that would be needed for a robust study. (The summary is available on the MDH website
at: Handout - Nurse Sensitive Outcome Measures.)
A particular challenge is the lack of alignment of timing for the readily available data: Data on claims will
be from calendar year 2012 (and 2013 soon), data on key outcomes will be from calendar year 2013,
and data on staffing will be from January – March 2014. Stefan asked the group to consider these timing
differences—MDH would appreciate the group’s thoughts on this issue. How would this gap between
staffing and claims data affect the study or the use of the study’s findings? (The group discussed this
topic after the presentation on MDH’s tentative approach to the study; notes are below.)
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Tentative staged approach
Nate Hierlmaier described the options MDH has developed for the study. A copy of the full presentation
is available on the MDH website at: MDH Presentation – Tentative Study Approach.
Nate thanked the workgroup for their advice so far—this has been a very helpful process. MDH is at the
mid-point in the overall timeline for the study, so it’s necessary to move forward on research in advance
of the released data from the Minnesota Hospital Association.
There are main phases that MDH identified for this research:
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Short term (April – June 2014):
o Examine staffing plan data from MHA—this will help determine if there is variation
among hospitals in terms of staffing (and if so, how much).
o Explore existing available data, including Hospital Annual Report (HAR) data, Hospital
Adverse Health Events data, and Hospital Discharge data.
o Conduct preliminary research on outcomes.
o Refine study approach.
Medium term (July – December 2014)—data will be available from MHA staffing reports.
Potentially longer term—though MDH is not charged with conducting additional research after
the report to the legislature, MDH hopes to identify additional areas for research or data
collection.
Nate explained that the differences in timing of staffing data and outcome data lead to different options
for connecting and analyzing the data, and all the options have significant limitations. Given the data
that are currently available, these are the options that seem to have the most potential for conducting
useful research.
Workgroup discussion to inform MDH’s approach
Kris facilitated a discussion, asking members for feedback and thoughts about the presentations and
about MDH’s tentative approach.
Several workgroup members expressed appreciation for MDH’s work in developing these approaches.
Several members indicated that there has been a large amount of information presented at once, which
makes it difficult to make informed comments today.
Workgroup members were invited to share any initial comments at the meeting and to follow up via
email.
For easier reference, the group’s discussion is presented under the headings below (comments are not
in sequence).
General comments and thoughts on the study as a whole
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There are many studies on the correlation of nurse staffing and patient outcomes—MDH has
been asked to study this question on the ground in Minnesota.
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Of course there’s a relationship between nurse staffing and patient outcomes, but the real
question is: where is the break point? That question may be better answered in an academic
study than in the present MDH study and report to the legislature.
There’s a reason why there hasn’t been research showing at what level staffing constraints
become a challenge to patient safety—it’s because that’s a complicated issue.
Minnesota has some of the best outcomes nationally—we all want to see the correlation
between staffing patterns and patient outcomes, but we realize there are limits to the current
study.
MDH could explain that any conclusions drawn are limited by the data available and how it
aligns over time. Could MDH also advise the legislature about possibilities and costs for next
steps in this area of research?
MDH can present the study to the legislature with discussions of limitations of data and current
inability to account for all of the important confounding variables.
MDH’s report can include the context and perspectives brought forward by this group—
including the frustrations about available data.
MDH can share existing research with the legislature.
MDH will be reporting on correlations between nurse staffing and patient outcomes—they
won’t be saying whether staffing is too low or too high.
MDH explained in the fiscal note for the legislation that requires the study that available data
may not be sufficient to answer the question posed.
To get more robust answers, Minnesota may need to partner with other states (regionally or
nationally).
MDH has to work within the timeline and direction set by the legislature.
This workgroup and the study have the potential to contribute to knowledge around this topic—
that still seems possible even within the limitations identified.
MDH plans to work with colleagues who have significant experience in this area of research.
MDH plans to connect with research going on in Massachusetts and California.
Comments on options presented and on aligning data reporting periods
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Option 2 (analyzing data from different time periods) would not be helpful—it would be
challenging to use the results. (Several members offered this opinion.)
A possibility: create a hybrid of Options 1 and 3 by examining the aligned first quarter data and
then examining other data (state or national) to see if it tracks similar patterns.
Is there enough analyst time to do both Options 1 & 3? Option 3 could provide some unique
analysis and get at important factors, but it doesn’t get to the unit level.
Answering the short term question about staffing variation is necessary—if there are not
meaningful differences in staffing patterns in Minnesota hospitals, then that finding will impact
the rest of the study.
The time lag on the data is a significant issue. It may be necessary to obtain additional data from
hospitals to get claims data that matches the timing for staffing data, or it may be necessary to
wait for claims data for 2014 (which would be outside the study’s timeline).
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The time lag is an issue for this study and timeline, but as the data collection goes forward into
future years, it will be less of an issue.
Comments on data and data sources
Data on claims, outcomes, and confounding variables
 MDH has access to hospital claims data through MHA—this is voluntarily submitted data. The
hospital claims data includes information on diagnostics, procedures, demographics, cause of
admission, reason for discharge, date of discharge—it’s a rich data set for what occurred in the
hospital, but there are weaknesses (including that patients are not tracked across hospitals).
 MDH also has data for hospitalization of Minnesota residents out of state (though that may not
be particularly useful for this study).
 The University of Minnesota School of Nursing is taking the lead on a project that is establishing
national standards on some of the elements identified by this group (such as nurse experience,
unit types, and organizational culture). These have been standardized to the LOINC standard.
Connie Delaney will send this information to MDH.
 Data on these confounding variables may not be available now, but data collection will be within
the realm of possibility soon. It would require data collection time, but the work on comparable
measures has been done.
 This standardization work presents an opportunity for Minnesota—Minnesota could be an
exemplar of using data to show nursing’s impact on patient outcomes.
 Other data that might be useful is collected by the NDNQI (a national database).
 Data that can be found at unit level: some outcome metrics (claims data).
 A concern: some of these outcomes may not be linked to specific activities. For example, a skin
problem may develop over time and have no connection to the activity in the unit the problem
is reported in.
 All quality measures have that potential problem—they suffer from the reality that they are not
covering unique events.
Other data comments
 National patterns and data may be useful—MDH will need to make sure the studies and
hospitals are comparable.
 The staffing data being considered is very limited—it’s not looking at shifts or qualifications of
staff. There may be huge differences that don’t show up in the data.
 A concern: all the data being discussed is coming from the hospitals. Will the data be
meaningful and complete?
 Data reported by hospitals is not manipulated—the hospitals are using common measures
across facilities.
 Perhaps the Minnesota Nurses Association will be able to offer assistance in identifying other
sources of data.
 The Minnesota Hospital Association may not be statutorily required to report some data, but
they may be able to report more useful information. It seems likely that MHA is collecting other
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relevant information to compile the staffing reports—would they be willing to disclose this
information?
Some of these issues and concerns related to staffing data were voiced during the discussion of
the legislation that led to this workgroup and study.
Closing comments
Diane and Stefan acknowledged that the group was presented with a lot of information for the first time
today, and that members will need time to consider their feedback. A follow-up email with a request for
information will be sent to the group—the email will ask for feedback on specific topic areas, but any
and all feedback is welcome.
MDH will send periodic progress reports to the group as the study progresses (such as a summary of the
group’s feedback and decisions about options for the study).
Kris, Diane, Nate, and Stefan closed the meeting by thanking the workgroup for their participation.
Future meetings
The next meeting of the workgroup will be in late 2014.
Summary prepared by: Beth Bibus, Management Analysis & Development, Minnesota Management &
Budget
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